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Nebraska not alone in struggle to find mental health workers

The Schuyler Sun
Jul 19, 2017

The shortage of mental health staff in Nebraska prisons has been a topic in every discussion that Department of Correctional Services Director Scott Frakes has had with lawmakers in the past two years.

Now, a former prison doctor is sounding an alarm about the struggle the department is having finding psychiatrists.

Without proper medical oversight of treatment of confined patients with mental health disorders, the state of Nebraska is open to legal liability, not simply extending to the rights of patients but to the safety of its employees, said Lincoln psychiatrist Subramanyam Rajagopal.

The doctor worked for the department from 2008 to 2010 as the first psychiatrist in a new mental health unit at the Lincoln Correctional Center. He left because of the stress of having 60 patients under his care, he said, and did not leave on good terms.

Since then, there has been high turnover of department psychiatrists, he said. But many of the mental health administrators who were there when he left are gone, and the department recently contacted him to interview for a position as an independent contractor. He went in for two interviews, but decided not to return, he said.

The department's only psychiatrist, Dr. Natalie Baker, left June 16, but is consulting with department doctors on challenging cases as requested, said Dr. Harbans Deol, the prisons' medical director.

Rajagopal believes that without a psychiatrist on staff, the department is making compromises in care. For example, he said, prescriptions for the drug Clozaril, taken by several inmates for schizophrenia, should only be written by a psychiatrist, and weekly re-evaluations done by a psychiatrist, because of its severe side effects.

Deol said he knows of no guidelines that require a psychiatrist only to prescribe and monitor patients taking the drug.

Also, Rajagopal said, there are inmates on court-ordered medication injections that require testimony of two psychiatrists to continue the treatments when the medications are given against the will of the inmates. Without court permission, he said, an unwilling patient cannot be given the medication.

Without proper medical management of mentally ill inmates, Rajagopal believes the violence that has been an issue in the past two years - a riot, serious disturbances, killings of inmates, an assault in the community by an escapee and assaults on corrections staff - will get worse.

Deol said there's no correlation between mental health care and violence in the prisons.

But inmates have complained they go long periods of time without needed counseling or group therapy, and it creates stress.

"Dutiful action is urgent and imperative," Rajagopal said.

Proper mental health care is good for the prisons and the communities to which inmates return, according to a 2015 review of Nebraska inmate mental health services by consultant Dr. Bruce Gage of the Washington State Department of Corrections.

With it, the department has the opportunity to reduce disciplinary infractions and behavioral disruptions, allow for better program participation and reduce the number of crimes committed after an offender is released, Gage's report said.

Prisons in Nebraska and across the country have seen increasing numbers of offenders with mental illness since 1997, when mental health beds in communities began decreasing, said Deol. The prisons have essentially become de facto mental health institutions.

That's hard not only for inmates, but for the staff, he said.

Two years ago, Gage's report showed that about one-fourth of 4,800 male inmates and half of 430 women in the prisons were on one or more psychotropic medications.

A conservative estimate, he said, is that 3 to 6 percent have a psychotic or schizophrenia disorder and 10 percent have significant depression or bipolar disorder. The remainder have less-severe conditions.

Deol said the department is meeting psychiatric needs with a psychiatric nurse practitioner, who can prescribe medications, the use of a contract staffing agency and tele-psychology services.

The department's behavioral health team is strong, he said, with every facility having two to four licensed psychologists available or managing triage for mentally ill patients.

In addition, two fourth-year psychiatric residents have been moonlighting on weekends at the Diagnostic and Evaluation Center, where the biggest need is, he said. And a third resident is interested in working at the Lincoln Correctional Center.

Deol said the department is working hard to recruit people, and has interviewed at least four psychiatrists in recent months.

Pay is an issue, he said. Across the country, some psychiatrists have asked for as much as $500,000 annually, and at least a couple of positions offering $400,000 have had zero takers.

In 2016, the clinical psychiatrist for the Nebraska Department of Corrections was being paid $255,000 annually, according to state salary listings.

The Department of Health and Human Services has 11 psychiatrists at the state's regional centers and community health services, with two current vacancies. Those psychiatrists earn between $184,000 to $327,000, according to the listing.

Other states have a variety of ways to staff their Corrections mental health services.

In Wyoming, the Department of Corrections contracts with Corizon Health, a national correctional health services company, said Laura McKinnon, mental health director. The company is constantly networking to identify behavioral health professionals interested in working in that environment.

"We have not had any lapses in coverage in the past 15 years," McKinnon said. "From time to time we have had mental health therapy vacancies, but are able to work as a team across the state to maintain a high standard of care for our patients."

Psychiatrist Jerome Greenfield, who has worked for the Iowa Department of Corrections three years, said it's not only Nebraska that is struggling to find psychiatrists.

He was recently promoted to health services administrator there, but also continues to work as a psychiatrist for the Iowa Correctional Institution for Women until his replacement arrives in September, he said. And all the while, he gets daily calls from head hunters with opportunities for employment.

"There's just such a dire shortage everywhere," he said. "It's very concerning and difficult."

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